Help your patient combat postoperative atelectasis With education, demonstration, and reinforcement, you can help her avoid or minimize

this dangerous pulmonary complication. By Bill Pruitt, RRT, AE-C, CPFT, MBA

www.nursing2006.com Nursing2006, May 64hn1

Jill Blackburn, 59, is a patient in the telemetrystep-down unit. Having undergone coronaryartery bypass graft (CABG) surgery 3 days ago,

she’s receiving 3 liters/minute of oxygen by nasalcannula. During your assessment, her SpO2 readingis 91% and her temperature is 100.1° F (37.8° C).Auscultating her lungs, you hear diminished breathsounds on the left and fine inspiratory crackles inboth posterior bases.

You ask Mrs. Blackburn to perform incentivespirometry and she growls, “Don’t you know theyjust cut me open from my neck to my navel? Leaveme alone!”

Surgery places a patient at risk for atelectasis, (col-lapsed alveoli) and subsequent pneumonia. Mrs.Blackburn’s current signs and symptoms indicate thatshe may indeed have these complications. In this arti-cle, I’ll explain how you can help her now andhow you can help other patients avoid similarproblems.

How surgery increases riskRegardless of the surgical procedure, 90% ofpatients who have general anesthesia developsome degree of atelectasis afterward. The signsand symptoms include tachypnea, tachycardia,hypoxemia, and diminished breath sounds. Inareas of consolidation, you’ll hear bronchialbreath sounds and fine, late-inspiratory crack-les. Chest X-rays reveal opacification of the af-fected lung segment or lobe.

The following factors increase the risk ofatelectasis in a surgical patient:• Anesthesia causes the diaphragm to relaxand move into the chest cavity, reducing func-tional residual capacity (FRC) and compress-ing the alveoli. The longer the anesthesia, thegreater the risk.• Low ventilator settings, particularly for tidal

volume, may cause hypoventilation and alveolar col-lapse.• Delivering too much oxygen to the alveoli over anextended period can wash out nitrogen (whichshares alveolar space and helps keep the alveoliopen) to trigger atelectasis.• Postoperative hypoventilation can be a problemafter abdominal or thoracic surgery if pain preventsthe patient from deep breathing and effectivecoughing. Retained secretions and reduced ventila-tion can lead to mucus plugs in her airway and in-crease atelectasis.• Smoking or chronic obstructive pulmonary disease(COPD) raises the risk by increasing mucus produc-tion and decreasing mucociliary action to clear secre-tions. Chronic air trapping and increased FRC com-press the airways, reducing their diameter and

Putting on airs

Most incentive spirometers have an oxygen port, a volume indicator(a piston inside a calibrated cylinder), and a flow indicator (a “float”inside a chamber to show inspiration rate). During inspiration, thepiston rises to a peak level then drops slowly when inspiration ends.Inhaling at the proper rate causes the float to hover in the target

range then drop assoon as inspiratoryflow stops.

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Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

64hn4 Nursing2006, Volume 36, Number 5 www.nursing2006.com

increasing the work of breathing. Finally, air trappingand increased FRC push down on the diaphragm tocause ineffective diaphragmatic contractions.• Coronary artery bypass graft surgery poses severalrisks. Opening the chest and exposing the lungs toair can trigger alveolar collapse. Or the surgeonmight compress lung tissue by infusing lavage fluidinto the pericardial sac or by moving the lungs inorder to reach the coronary arteries.

Prevent and respond to the problemThese measures during and immediately aftersurgery help prevent atelectasis:• administering appropriate tidal volume on the mechanical ventilator• administering positive end-expiratory pressure(PEEP) to increase FRC• administering supplemental oxygen at the lowestsetting needed to prevent hypoxemia • weaning and extubating the patient from mechani-cal ventilation as soon as possible.

For both surgical and medical patients, positioningand encouraging deep breathing and coughing arekey nursing techniques to help prevent atelectasis.

Positioning. Keep Mrs. Blackburn in a semi-Fowler’s position and occasionally in high-Fowler’sposition to increase her lung capacity and encouragedeeper breaths. Get her up in a chair and walking assoon as possible.

Deep breathing and coughing, especially with theaid of an incentive spirometer. (See Putting on airs.)Using this calibrated device, the patient takes low,sustained maximal inspirations to total lung capacity,holds her breath, and exhales passively to help keepthe alveoli open. (This is done about 10 times everyhour while she’s awake.) Adequate pain control alongwith coaching and reinforcement are essential to helpher master the proper technique. A patient withCOPD may benefit from positive-pressure ventilation.(See the Photo Guide on page 46 of this issue.)

Teaching the techniqueThe ideal time to teach a patient incentive spirome-try is preoperatively so she can comfortably practice.Explain that breathing exercises will help her keepher lungs inflated and prevent problems such aspneumonia. (For tips on visual reinforcement, seePicturing a balloon.) Use this teaching sequence:

Assemble the incentive spirometer and check thepackage insert to determine your patient’s target vol-

ume based on height and age. Explain how the devicewill help her do breathing exercises and show her theparts. Have her sit up if she can.

Model the breathing exercise. Explain that she’llplace the mouthpiece in her mouth, pull in a full,slow, deep breath, hold it for 5 seconds, then slowlylet out her air. Mimic the technique: Hold an imagi-nary mouthpiece to your mouth, inhale a slow deepbreath, hold it 5 seconds, and slowly exhale.

Coach her through the maneuver. If she needs sup-plemental oxygen, attach the tubing to the spirometerport. Help her find her target on the volume indicator.

Facing your patient to coach her, have her inhaleslowly and watch the piston rising in the volumeindicator. As she inhales up to the target volume,have her watch the flow indicator and keep it in thetarget zone to ensure slow inhalation. After each fullinhalation, count out loud to five so she knows howlong to hold her breath before exhaling. Have her dothis exercise 10 times, pausing to breathe normally afew times between each one.

Review her technique. The patient may forget somedirections and make one of several common errors,such as blowing into the spirometer rather thaninhaling. Or her inspirations may be fast and deep,pulling the diaphragm down so air enters open alve-oli and misses those that are collapsed. Taking a deepbreath but failing to hold it for 5 seconds also bypass-es atelectatic areas. Taking in a slow, deep breath and

Picturing a balloon

Use imagery to help your patient understand theimportance of deep breathing and coughing:“Have you ever blown up a balloon, tied the opening,and set it aside? The next day, it’s lost air and shrunk.

“After surgery, tiny air sacks in your lungs called alve-oli can lose air too, partly because of the surgery andpartly because of other factors. For example, staying inbed keeps you from doing things that make youbreathe deeply, and pain makes deep breathing andcoughing difficult, so the alveoli can lose air and closeup like the balloon. Once they collapse, they’re hard toreopen.

If you don’t take deep breaths and cough, secretionsmay stay in your lungs, making breathing harder andproviding a good site for infection. I’ll help you takedeep breaths and learn how to cough without causing alot of pain to keep the alveoli open and move secre-tions out of your lungs.”

Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

holding it encourages air movement into those areasto start reopening the closed alveoli.

Have her end with two coughs. After 10 incentivespirometry maneuvers, your patient should cough tomove out chest secretions. If she’s scheduled forsurgery on her chest or abdomen, teach her to placea pillow over the area and wrap her arms around it.Instruct her to take a slow, deep breath, squeeze thepillow tightly against the painful area, and let out amedium cough, then a second strong one, then stop(repeated coughing is ineffective and causes morepain). Mimic this action as you did the inspirationtechnique.

Encourage practice. Place the incentive spirometerwithin easy reach on your patient’s bedside table.Each time you enter the room, ask her to do the exer-cise, or ask if she needs help.

Education pays offOnce Mrs. Blackburn’s pain is under control, youspend a few minutes teaching her about incentivespirometry and coaching her in the technique of

splinting a pillow against her chest. She starts doingthe exercise and achieves 60% to 80% of her in-spired volume goal each hour. Within 24 hours,she’s receiving oxygen by nasal cannula at 1liter/minute, her breath sounds are clear, and hertemperature is 98.9° F (37.2° C). Coughing withvigor, she’s maintaining her SpO2 level at or above94% while walking in the hall. Within 48 hours,she’s been weaned off supplementary oxygen and ispreparing for discharge.

Mrs. Blackburn is an example of how educationhelps motivate a patient to combat atelectasis. Yourcareful instruction and demonstration of incentivespirometry have helped her overcome postoperativerespiratory problems and prevent possible pulmonarycomplications.‹›SELECTED REFERENCESDuggan M, Kavanagh B. Pulmonary atelectasis: A pathogenic periopera-tive entity. Anesthesiology. 102(4):838-854, 2005.

Wilkins R. Lung expansion therapy. In Wilkins R, et al. (eds). Egan’s Fun-damental of Respiratory Care, 8th edition. St. Louis, Mo., Mosby, 2003.

Bill Pruitt is an instructor in the department of cardiorespiratory sciences at theUniversity of South Alabama in Mobile, and a p.r.n. respiratory therapist atSpringhill Medical Center in Mobile.

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